Why Your Periods Get Heavier in Perimenopause (and How to Cope)

As if mood changes, hot flashes, or vaginal dryness weren’t bad enough, some people also have to add heavy bleeding to the list of perimenopause symptoms. 

If you’re experiencing this yourself, know that it’s common. About one-third of women seek treatment for heavy bleeding, according to the American College of Gynecologists—but that doesn’t mean you should sweep it under the rug (1). 

For starters, changing your tampon constantly is a pretty miserable way to live, but in some cases, heavy bleeding can be a sign of a more serious health issue, experts say, so it’s always worth a trip to your OB-GYN even if you think it’s “just perimenopause.”

So why does perimenopause cause heavy bleeding? And, more importantly, what can you do about it? We spoke to perimenopause specialists to break down why your period might be suddenly untenable. Plus, we’re sharing a few potential solutions your OB-GYN might suggest to address heavy bleeding during perimenopause, ranging from diet changes to hormone therapy. 

About the Experts

Taniqua Miller, MD is a board-certified OB-GYN and national certified menopause practitioner. She’s the founder of Revival Telemedicine, providing empowering medical consultations and midlife coaching for those in perimenopause and beyond.

Lauren Streicher, MD is a clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine, a certified menopause practitioner of The Menopause Society, and the founding Medical Director of the Northwestern Medicine Center for Sexual Medicine and Menopause. 

What Are Heavy Periods (Menorrhagia)?

Heavy menstrual bleeding, or menorrhagia, is losing more blood than is typical during menstruation (2). Heavy bleeding is just one type of “abnormal uterine bleeding,” which could also include bleeding between periods, or earlier or later in your cycles than expected. (And yes, those period changes are also common during perimenopause.)

What’s “typical” will be different from person to person, Streicher says, but a guideline OB-GYNs use for “heavy” is bleeding so much that you’re changing your pad or tampon every hour for several hours back to back. Needing to wear more than one pad at a time or change pads or tampons in the middle of the night are also signs of heavy bleeding, as is bleeding that lasts for more than seven days or passing blood clots that are the size of a quarter or larger, according to ACOG (1). 

If it’s interfering with your quality of life, regardless of the specific amount of bleeding, it’s considered heavy menstrual bleeding (3). 

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When is menopause the cause?

One simple way to know if your heavier period is a result of heading towards menopause? Your age. “If you’re someone who never had problems before but now in your 40s you’re suddenly having heavy periods, certainly one possibility is that it’s perimenopause,” Streicher says. Perimenopause can begin in some women in their 30s, but most often it starts in women ages 40 to 44 (4).

It’s also important to remember that perimenopause can be a wildly different experience from person to person. While you could have many typical symptoms of perimenopause (like low libido or night sweats), an irregular period could also be the only symptom of perimenopause you experience, Streicher says.

She also points out that while perimenopause could be the reason for heavier bleeding, it might not be the only reason. There are often multiple boxes to check—for example, a history of polycystic ovary syndrome (PCOS) or endometriosis, she says.

What Causes Heavy Periods During Perimenopause?

When you’ve had no menstrual cycle for 12 months in a row, you have officially reached menopause. But the years leading up to that point are the transitional time known as perimenopause when your hormones are in flux. 

To recap what normally happens before your period: “You make estrogen, you ovulate, you make progesterone, you get a period,” Streicher says. During perimenopause, estrogen is still being produced by the ovaries, but you’re not necessarily ovulating. That means you don’t get progesterone to balance out the estrogen, and as a result, the lining of the uterus can get much thicker than normal and cause bleeding when you aren’t expecting it—or bleeding that’s much heavier than usual, Streicher says. (When a woman has irregular, infrequent menstrual periods or does not ovulate at all, she is said to have ‘ovulatory dysfunction’.) 

You may also hear your doctor talk about a hormone produced by the brain called follicular stimulating hormone (FSH), which sends a signal to the ovary to produce a crop of follicles, which then produces estrogen, Miller says. However, as you age, fewer and fewer follicles remain to be stimulated and thus estrogen levels decline. And when there isn’t enough estrogen to “turn off” the brain’s production of FSH it keeps sending more. That’s why FSH is sometimes used as a measure of whether a woman is peri or postmenopausal. 

Bottom line: “During perimenopause, the lining of the uterus gets mixed messages,” Streicher says, which can cause irregular bleeding.

Other potential causes

Sometimes though, perimenopause might just be happening at an age that coincides with other gynecologic problems surfacing, Streicher and Miller say. For example, women might have uterine fibroids (a common type of noncancerous tumor that can grow in and on your uterus) that are now growing to the point where they’re bleeding heavier than usual.

Heavy bleeding is also associated with obesity (5). “Women make estrogen in their fat cells, which is why women who are obese are at higher risk for uterine cancer, so certainly that’s one very big factor,” Streicher says. 

Lastly, sometimes heavy bleeding during perimenopause could actually be a miscarriage. “A lot of people think that if you’re in perimenopause, you can’t possibly get pregnant, when in fact you can,” Streicher says. However, these pregnancies often end in miscarriage due to age-related factors. “It really throws people off because they’re thinking, okay, I’m 43, I haven’t had a period in two months, I must be perimenopausal.”

In other words, if you’re dealing with abnormal uterine bleeding, your OB-GYN will evaluate all of these things first, rather than just chalking it up to perimenopause, Miller says. 

Is Heavy Bleeding Normal In Perimenopause?

While heavy bleeding is common in perimenopause, the American College of Gynecologists (ACOG) caution this isn’t the same as “normal” (1).

“There’s a lot of reasons why heavy bleeding might be happening, but it’s not normal. You don’t ignore it,” Streicher says. For example, in addition to fibroids or polyps, other causes of heavy bleeding include pelvic inflammatory disease (an infection of the upper female genital tract) or even pre-cancer and cancer (1). 

Rest assured, “heavy bleeding usually is not an indication of something serious,” Streicher says, but it’s always better to err on the side of caution to rule out a more serious health problem beyond the menopause transition. 

When You Should See a Doctor

If your bleeding is heavier than usual for you, you’ll want to see your doctor to get it checked out—period. 

There are a few other important signs to pay attention to: If your belly is sticking out, you have a lot of abdominal pressure, you’re experiencing fatigue, or there is any indication you might be anemic (more on that below), it’s time to see your doctor. 

Health Impact of Heavy Bleeding During Perimenopause

In some cases, blood loss from heavy periods can lead to a condition called iron-deficiency anemia. “If you’re bleeding heavy enough, you need to get a blood count to make sure you’re not anemic,” Streicher says. While it’s possible you won’t experience any symptoms, more serious iron-deficiency anemia can make you feel tired or weak and cause shortness of breath, dizziness, chest pain, or even heart problems (6). 

While it sounds scary, most healthy women won’t get anemic based on one period that’s a little bit heavier than usual, Streicher says. But it could become an issue if heavy bleeding has been going on for an extended period of time—or you have a low blood count to begin with, she says. 

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Treatment Options for Heavy Bleeding

After an evaluation that rules out other potential causes of your bleeding, your doctor might suggest a range of options depending on your medical history to help you manage heavy bleeding during perimenopause if it’s interfering with your quality of life. A few potential options: 

Hormone Therapy

Hormone therapy, which can help balance the amount of estrogen and progesterone in your body, can be helpful for heavy bleeding during perimenopause. This might mean a traditional contraceptive pill or ring if bleeding is the biggest concern, or other combinations, such as an IUD paired with an estrogen patch to help patients with menopausal symptoms who are also dealing with heavier bleeding, she adds. 

Hormone therapy can also refer to hormone replacement therapy, or HRT (also called menopause hormone therapy or MHT), which replaces the hormones that your body isn’t making enough of that can cause perimenopausal symptoms. Miller says this can be a good treatment option if you’re dealing with issues like hot flashes or vaginal dryness in addition to heavy bleeding. HRT can also offer other health benefits like improving your mood and sleep and reducing bone loss, so it’s something to talk to your doctor about to see if it’s right for you. 

Non-hormonal Therapies

Sometimes the answer could be even simpler. Your doctor could suggest things like taking ibuprofen or making changes to your diet or exercise regimen to help with heavy bleeding. 

NSAIDs

You probably know that nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can relieve menstrual cramps, but they can also help reduce bleeding, Miller says.

How do they work? When you’re menstruating, your body produces the hormone prostaglandin, which causes the contractions in your uterus that help your body to shed the lining of your uterus. Levels of prostaglandin are higher in women with heavy menstrual bleeding. But NSAIDs like ibuprofen help to slow down prostaglandin production—meaning less uterine shedding, fewer cramps, and less bleeding (7).

Miller recommends taking about 800mg of Ibuprofen every eight hours a day or two before bleeding is expected to start (admittedly, not always predictable during perimenopause) or once your period starts.

Lifestyle Modifications

Since weight can also be a factor for heavy bleeding, your doctor might suggest focusing on your diet or activity to help manage it. 

The best exercise routine for you will depend on your age and medical conditions, but it’s generally recommended to aim for at least 30 minutes of exercise a day, including a balance of aerobic exercise (e.g. brisk walking, hiking, or dancing) and resistance training (which can also be helpful for protecting against bone loss as you age) (4). As a bonus, some studies show exercise can also help reduce hot flashes (8). 

Maintaining a healthy diet with good sources of iron—including beans, dried fruits, eggs, lean red meat, salmon, iron-fortified breads and cereals, peas, tofu, and dark green leafy vegetables—can also help prevent iron deficiency anemia (6).